Therapy of Female Sexual Dysfunction

Zusammenfassung

Die sexuelle Dysfunktion der Frau ist eine häufig vorkommende Störung, die sich entscheidend auf Gesundheit und Wohlbefinden auswirkt. Studien zur Behandlung dieser Dysfunktion sind selten und die bisher durchgeführten Untersuchungen sind wissenschaftlich nicht stichhaltig, teils infolge der komplexen Art der Vorgänge. Es fehlt eine direkte Bewertung sowohl der Pathologie als auch des Behandlungserfolges; die Korrelation zwischen den physischen Auswirkungen und dem subjektiv einzuschätzenden Behandlungserfolg ist gering.

Die Untersuchung der sexuellen Dysfunktion der Frau wird durch eine Vielfalt widerstreitender Faktoren erschwert, wobei sowohl emotionelle als auch Beziehungsprobleme einen entscheidenden Einfluss auf die Körperfunktionen ausüben. Der folgende Beitrag gibt eine Übersicht über den gegenwärtigen Stand der Erforschung der sexuellen Dysfunktion der Frau seit der ersten Dokumentation des menschlichen sexuellen Verhaltens durch Masters und Johnson 1966. Die wichtigsten Ziele waren:- eine Untersuchung der gegenwärtig angebotenen Möglichkeiten zur Behandlung der sexuellen Störungen und Dysfunktionen der Frau und eine Einschätzung deren Wirksamkeit aufgrund vorliegender Ergebnisse;- Aufzeigung derjenigen Gebiete, auf denen unzureichende oder nicht zugängliche Ergebnisse vorliegen, um die Aufmerksamkeit auf diese für zukünftige Forschungen zu lenken.

Schlüsselwörter

Sexuelle Dysfunktion der Frau - Behandlung - sexuelle Dysfunktion induziert durch selektive Serotonin-Wiederaufnahmehemmer - Psychotherapie

References

• 1 Aksray G, Yelken B, Kaptanoglu C, Oflu S, Ozaltin M. Sexuality in women with obsessive compulsive disorder.  J Sex Marital Ther. 2001;  27 273-277
• 2 Anderson B L. A comparison of systemic desensitisation and directed masturbation in the treatment of primary orgasmic dysfunction in females.  J Consult Clin Psychol. 1981;  49 568-570
• 3 Anderson J M, Blue C, Lau A. Women's perspectives on chronic illness: ethnicity, ideology and restructuring of life.  Soc Sci Med. 1991;  33 101-113
• 4 Anderson-Hunt M, Dennerstein L. Oxytocin and Female Sexuality.  Gynecol Obstet Invest. 1995;  40 217-221
• 5 Anderson-Hunt M, Dennerstein, L. Increased female sexual response after oxytocin [comment].  BMJ. 1994;  309 392
• 6 Arlt W, Callies F, van Vlijmen J C, Koehler I, Reincke M, Bidlingmaier M. Dehydroepiandrosterone replacement in women with adrenal insufficiency.  New Eng J of Med. 1999;  341 1013-1020
• 7 Ashton A K, Rosen R C. Accommodation to serotonin reuptake inhibitor-induced sexual dysfunction.  J Sex Marital Ther. 1998;  24 191-192
• 8 Ayton R A, Darling G M, Murkies A L, Farrell E A, Weisberg E, Selinus I, Fraser I D. A comparative study of safety and efficacy of continuous low dose estradiol released from a vaginal ring compared with conjugated equine estrogen vaginal cream in the treatment of postmenopausal vaginal atrophy.  Br J Obstet Gynaecol. 1996;  103 351-358
• 9 Barbach L, Flaherty M. Group treatment of situationally orgasmic women.  J Sex Marital Ther. 1980;  6 19-29
• 10 Barbach L G. Group treatment of preorgasmic women.  J Sex Marital Ther. 1974;  1 139-145
• 11 Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, Goldstein I, Graziottin A, Heiman J, Laan E, Leiblum S, Padma-Nathan H, Rosen R, Segraves K, Segraves R T, Shabsigh R, Sipski M, Wagner G, Whipple B. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. Presented at Consensus Development Conference.  J Urol. 2000;  163 888-893
• 12 Baulieu E, Thomas G, Legrain S, Lahlou N, Roger N, Debuire B. Dehydroepiandrosterone (DHEA), DHEA sulphate, and aging: contribution of the DHEAge Study to a sociobiomedical issue.  Proc Natl Acad Sci USA. 2000;  97 4279-4284
• 13 Beregon S, Binik Y M, Khalife S, Pagidas K, Glazer H I, Meana M, Amsel R. A randomised comparison of group cognitive-behavioural therapy, surface electromyographic biofeedback and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis.  Pain. 2001;  91 297-306
• 14 Berman J R, Adhikari S P, Goldstein I. Anatomy and physiology of female sexual function and dysfunction: classification, evaluation and treatment options.  Eur Urol. 2000;  38 20-29
• 15 Blaicher W, Gruber D, Bieglmayer C, Blaicher A M, Knogler W, Huber J C. The role of oxytocin in relation to female sexual arousal.  Gynecol Obstet Invest. 1999;  47 125-126
• 16 Blakeney P, Kinder B N, Creson D, Powell L C, Sutton C. A short-term, intensive workshop approach for the treatment of human sexual inadequacy.  J Sex Marital Ther. 1976;  2 124-129
• 17 Boykoff S L. Strategies for sexual counseling of patients following a myocardial infarction.  Dimensions of Critical Care Nursing. 1989;  8 368-373
• 18 Brady J P. Brevital-relaxation treatment of frigidity.  Behav Res Ther. 1966;  4 71-77
• 19 Brown J M, Chaves J F. Hypnosis in the treatment of sexual dysfunction.  J Sex Marital Ther. 1980;  6 63-74
• 20 Butcher J. ABC of sexual health: female sexual problems I: loss of desire - what about the fun?.  BMJ. 1999;  318 41-43
• 21 Caird W K, Wincze J P. Videotaped desensitization of frigidity.  J Behav Ther Exp Psychiatry. 1974;  5 175-178
• 22 Carney A, Bancroft J, Matthews A. Combination of hormonal and psychological treatment for female sexual unresponsiveness: A comparative study.  Br J Psychiatry. 1978;  133 339-346
• 23 Caruso S, Intelisano G, Lupo L, Agnello C. Premenopausal women affected by sexual arousal disorder treated with sildenafil: a double-blind, cross-over, placebo-controlled study.  Br J Obstet Gynaecol. 2001;  108 623-628
• 24 Chua   Chee   Ann. A proposal for a radical new sex therapy technique for the management of vasocongestive and orgasmic dysfunction in women: The AFE Zone Stimulation Technique.  Sex & Marital Ther. 1997;  12 357-370
• 25 Clement U, Schmidt G. The outcome of couple therapy for sexual dysfunction using three different formats.  J Sex Marital Ther. 1983;  9 67-78
• 26 Collins A, Landgren B M. Reproductive health, use of estrogen and experience of symptoms in perimenopausal women: a population-based study.  Maturitas. 1994;  20 101-111
• 27 Cooper A J. Frigidity, treatment and short-term prognosis.  J Psychosom Res. 1970;  14 133-147
• 28 Covarrubias L D. The relationships among disposition toward fantasy, force fantasy, sexual dysfunction, satisfaction, and female sex abuse history. Dissertation Abstracts International: Section B: the Sciences & Engineering. 1997; Vol 57 (7-B), Jan
• 29 Crenshaw T L, Goldberg J P, Stern W C. Pharmacologic modification of psychosexual dysfunction.  J Sex Marital Ther. 1987;  13 239-252
• 30 Croft H, Settle E, Houser T, Batey S R, Donahue R M, Ascher J A. A placebo controlled comparison of the antidepressant efficacy and effects on sexual functioning of sustained-release bupropion and sertraline.  Clinical Therapeutics. 1999;  21 643-658
• 31 Davis S R, McCloud P, Strauss B JG, Burger H. Testosterone enhances estradiol's effects on postmenopausal bone density and sexuality.  Maturitas. 1995;  21 227-236
• 32 DeAmicis L, Goldberg D C, LoPiccolo J, Friedman J, Davis L. Clinical follow-up of couples treated for sexual dysfunction.  Arch Sex Behav. 1985;  14 467-489
• 33 DeJong J, Ramakers M, van Lunsen R. Vulvar vestibulitis syndrome: a review. Dynamics of a painful syndrome.  Tijdschrift voor Seksuologie. 1998;  22 52-61
• 34 Dennerstein L, Burrows G D, Hyman G J, Sharpe K. Hormones and sexuality: effects of estrogen and progestogen.  Obstet Gynecol. 1980;  56 316-322
• 35 Dennerstein L, Callan A, Warne G ,. et al . The effects of benzodiazepines on hormones in women with idiopathic hirsutism.  Prog Neuropsychopharmacol Biol Psychiatry. 1984;  8 11-17
• 36 Dennerstein L, Dudley E, Hopper J, Burger H. Sexuality, hormones and the menopausal transition.  Maturitas. 1997;  26 83-93
• 37 Dennerstein L, Lehert P, Burger H, Dudley E. Factors affecting sexual functioning of women in the midlife years.  Climacteric. 1999;  2 254-262
• 38 Dennerstein L, Lehert P, Dudley E. Short scale to measure female sexuality: Adapted from McCoy Female Sexuality Questionnaire.  J Sex Marital Ther. 2001;  27 339-351
• 39 Dennerstein L, Dudley E, Burger H. Are changes in sexual functioning during midlife due to aging or menopause?.  Fertil Steril. 2001;  76 456-460
• 40 Devan G S. An overview of sexual counselling.  Ann Acad Med Singapore. 1995;  24 732-735
• 41 Eichel E W, Eichel J D, Kule S. The technique of coital alignment and its relation to female orgasmic response and simultaneous orgasm.  J Sex Marital Ther. 1988;  14 129-141
• 42 Ersner-Hershfield R, Kopel S. Group treatment of preorgasmic women: Evaluation of partner involvement and spacing of sessions.  J Consult Clin Psychol. 1979;  47 750-759
• 43 Fagan P J, Schmidt C W, Wise T N, Derogatis L R. Sexual dysfunction and dual psychiatric diagnoses.  Compr Psychiatry. 1988;  29 278-284
• 44 Fichten C S, Libman E, Brender W. Methodological issues in the study of sex therapy: Effective components in the treatment of secondary orgasmic dysfunction.  J Sex Marital Ther. 1983;  9 191-202
• 45 Gilmore L G. Hypnotic metaphor and sexual dysfunction.  J Sex Marital Ther. 1987;  13 45-57
• 46 Gitlin M J. Psychotropic medications and their effects on sexual function: diagnosis, biology, and treatment approaches.  J Clin Psychiatry. 1994;  55 406-413
• 47 Goldstein I, Berman J R. Vasculogenic female sexual dysfunction: Vaginal engorgement and clitoral erectile insufficiency syndromes.  Int J Impot Res. 1998;  10 (Supl 2) S84-S90
• 48 Hawton K, Catalan J, Martin P, Fagg J. Long-term outcome of sex therapy.  Behav Res & Ther. 1986;  24 665-675
• 49 Hawton K. Treatment of sexual dysfunctions by sex therapy and other approaches.  Br J Psychiatry. 1995;  167 307-314
• 50 Heiman J R, LoPiccolo J. Clinical outcome of sex therapy. Effects of daily v weekly treatment.  Arch Gen Psychiatry. 1983;  40 443-449
• 51 Henrich A G. The effect of group and self-directed behavioural educational treatment of primary orgasmic dysfunction in females treated without their partners. Dissertation Abstracts International. 1976; 37: 1902 B
• 52 Henson C, Rubin H B, Henson D E. Women's sexual arousal concurrently assessed by three genital measures.  Arch Sex Behav. 1979;  8 459-469
• 53 Hulter B, Berne C, Lundberg P O. Sexual function in women with insulin dependent diabetes mellitus.  Scand J Sexology. 1998;  1 43-50
• 54 Hurlbert D F, Apt C. The coital alignment technique and directed masturbation: A comparative study on female orgasm.  J Sex Marital Ther. 1995;  21 21-29
• 55 Husted J R. Desensitization procedures in dealing with female sexual dysfunction.  The Counseling Psychologist. 1975;  5 30-37
• 56 Ince L P. Behaviour modification of sexual disorders.  Am J Psychother. 1973;  27 446-451
• 57 Jankovich R, Miller P R. Response of women with primary orgasmic dysfunction to audiovisual education.  J Sex Marital Ther. 1978;  4 16-19
• 58 Jones W, Park P. Treatment of single partner sexual dysfunction by systematic desensitisation.  Obstet Gynecol. 1972;  39 411-417
• 59 Kaplan S A, Reis R B, Kohn I J, Ikeguichi E F, Laor E, Te A E, Martins A C. Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction.  Urology. 1999;  53 481-486
• 60 Kilmann P R, Milan RJ J r, Boland J P, Mills K H, Caid C, Davidson E, Bella B, Wanlass R, Sullivan J, Montgomery B. The treatment of secondary orgasmic dysfunction II.  J Sex Marital Ther. 1987;  13 93-105
• 61 Kilmann P R, Mills K H, Bella B, Caid C, Davidson E, Drose G, Wanlass R. The effects of sex education on women with secondary orgasmic dysfunction.  J Sex Marital Ther. 1983;  9 79-87
• 62 Kilmann P R, Mills K H, Caid C, Davidson E, Drose G, Boland J, Follingstand D, Montgomery B, Wanlass R. Treatment of secondary orgasmic dysfunction: An outcome study.  Arch Sex Behav. 1986;  15 211-229
• 63 Kinzl J F, Traweger C, Biebl W. Sexual dysfunctions: relationship to childhood sexual abuse and early family experiences in a nonclinical sample.  Child Abuse Negl. 1995;  19 785-792
• 64 Kohlenberg R J. Directed masturbation and the treatment of primary orgasmic dysfunction.  Arch Sex Behav. 1974;  3 349-356
• 65 Kraft T, Al-Issa I. Behaviour therapy and the treatment of frigidity.  Am J Psychother. 1967;  21 116-120
• 66 Kuriansky J B, Sharpe L, O'Conner D. The treatment of anorgasmia: long term effectiveness of a short term behavioural group therapy.  J Sex Marital Ther. 1982;  8 29-43
• 67 Laan E, Everaerd W. Physiological measure of vaginal vasocongestion.  Int J Impot Res. 1998;  10 S 107-S 110
• 68 Laumann E O, Paik A, Rosen R C. Sexual dysfunction in the United States: prevalence and predictors.  J Am Med Assoc. 1999;  281 537-544
• 69 Leiblum S R, Ersner-Hershfield R. Sexual enhancement groups for dysfunctional women: An evaluation.  J Sex Marital Ther. 1977;  3 139-152
• 70 Levin R J, Wagner G. Orgasm in women in the laboratory - quantitative studies on duration, intensity, latency, and vaginal blood flow.  Arch Sex Behav. 1985;  14 439-449
• 71 Lobitz W C, LoPiccolo J. New methods in the behavioural treatment of sexual dysfunction.  J Behav Ther Exp Psychiatry. 1972;  3 265-271
• 72 LoPiccolo J, Heiman J R, Hogan D R, Roberts C W. Effectiveness of single therapist versus co-therapy teams in sex therapy.  J Consult Clin Psychol. 1985;  53 287-294
• 73 LoPiccolo J, Lobitz W C. The role of masturbation in the treatment of orgasmic dysfunction.  Arch Sex Behav. 1972;  2 163-171
• 74 Madsen CH J r, Ullmann L P. Innovations in the desensitisation of frigidity.  Behav Res Ther. 1967;  5 67-68
• 75 Masand P S, Ashton A K, Gupta S, Frank B. Sustained-release bupropion for selective serotonin reuptake inhibitor-induced sexual dysfunction: a randomized, double-blind, placebo-controlled, parallel-group study.  Am J Psychiatry. 2001;  158 805-807
• 76 Masters W H, Johnson V. Human sexual inadequacy. Boston, Little Brown & Co. 1970
• 77 Masters W H, Johnson V E. Human sexual response. Boston, Little Brown & Co. 1966
• 78 Mathew R J, Weinman M L. Sexual dysfunctions in depression.  Arch Sex Behav. 1982;  11 323-328
• 79 Mathews A, Bancroft J, Whitehead A, Hackmann A, Julier D, Bancroft J, Fath D, Shaw P. The behavioural treatment of sexual inadequacy: A comparative study.  Behav Res Ther. 1976;  14 427-436
• 80 Mathews A, Whitehead A, Kellett J M. Psychological and hormonal factors in the treatment of sexual female dysfunction.  Psychol Med. 1983;  13 83-92
• 81 Mathews A. Progress in the treatment of female sexual dysfunction.  J Psychosom Res. 1983;  27 165-173
• 82 Mattson D, Petrie M, Srivastava D K, McDermott M. Multiple sclerosis. Sexual dysfunction and its response to medications.  Arch Neurol. 1995;  52 862-868
• 83 McGovern K B, Kirkpatrick C, LoPiccolo J. A behavioural group treatment program for sexually dysfunctional couples.  J Marriage & Family Counselling. 1976;  2 397-404
• 84 McGovern K B, Stewart R C, LoPiccolo J. Secondary orgasmic dysfunction: 1 Analysis and strategies for treatment.  Arch Sex Behav. 1975;  4 265-275
• 85 McMullen S, Rosen R C. Self-administered masturbation training in the treatment of primary orgasmic dysfunction.  J Consult Clin Psychol. 1979;  47 912-918
• 86 Meston C M, Heiman J R. Ephedrine activated physiological sexual arousal in women.  Arch Gen Psych. 1998;  55 652-656
• 87 Milan R J, Kilman P R, Boland J P. Treatment outcome of secondary orgasmic dysfunction: A two to six year follow-up.  Arch Sex Behav. 1988;  17 463-480
• 88 Mills K H, Kilmann P R. Group treatment of sexual dysfunctions: a methodological review of the outcome literature.  J Sex Marital Ther. 1982;  8 259-296
• 89 Monga T N, Lawson J S, Inglis J. Sexual dysfunction in stroke patients.  Arch Phys Med Rehabil. 1986;  67 19-22
• 90 Morokoff P J, LoPiccolo J L. A comparative evaluation of minimal therapist contact and 15 session treatment of organic dysfunction.  J Consult Clin Psychol. 1986;  54 294-300
• 91 Munjack D, Cristol A, Goldstein A, Philips D, Goldberg A, Whipple K, Staples F, Kenno P. Behavioural treatment of orgasmic dysfunction: A controlled study.  Br J Psychiatry. 1976;  129 497-502
• 92 Nelson E B, Shah V N, Welge J A, Keck  P E. A placebo-controlled, crossover trial of granisetron in SSRI-induced sexual dysfunction.  J Clin Psychiatry. 2001;  62 469-473
• 93 Nemetz G H, Craig K D, Reith G. Treatment of female sexual dysfunction through symbolic modelling.  J Consult Clin Psychol. 1978;  46 62-73
• 94 O'Gorman E C. The treatment of frigidity: a comparative study of group and individual desensitisation.  Br J Psychiatry. 1978;  132 580-584
• 95 Palace E M, Gorzalka B B. The enhancing effects of anxiety on arousal in sexually dysfunctional and functional women.  J Abnorm Psychol. 1990;  99 403-411
• 96 Philipp M, Tiller J W, Baier D, Kohnen R. Comparison of moclobemide with selective serotonin reuptake inhibitors (SSRIs) on sexual function in depressed adults. The Australian and German Study Groups.  Eur Neuropsychopharmacol. 2000;  10 305-314
• 97 Piazza L A, Markowitz J C, Kocsis J H, Leon A C, Portera L, Miller N L, Adler D. Sexual functioning in chronically depressed patients treated with SSRI antidepressants: A pilot study.  Am J of Psychiatry. 1997;  154 1757-1759
• 98 Ramage M. ABC of sexual health: Management of sexual problems.  BMJ. 1998;  317 1509-1512
• 99 Ravart M, Cote H. Sexoanalysis: a new insight-oriented treatment approach for sexual disorders.  J Sex Marital Ther. 1992;  18 128-140
• 100 Redmond G P. Hormones and sexual function.  Int J Fertil & Women's Med. 1999;  44 193-197
• 101 Resinger J J. Masturbatory training in the treatment of primary orgasmic dysfunction.  J Behav Ther Exp Psychiatry. 1974;  5 179-183
• 102 Riley A J, Riley E J. A controlled study to evaluate directed masturbation in the management of primary orgasmic failure in women.  Br J Psychiatry. 1978;  133 404-409
• 103 Rosen R C, Beck J G. Patterns of sexual arousal.  New York, The Guilford Press 1988
• 104 Rothschild A J. Selective serotonin reuptake inhibitor-induced sexual dysfunction: efficacy of a drug holiday.  Am J Psychiatry. 1995;  152 1514-1516
• 105 Rumstein-McKean O, Hunsley J. Interpersonal and family functioning of female survivors of childhood sexual abuse.  Clin Psychology Review. 2001;  21 471-490
• 106 Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy.  J Reprod Med. 1998;  43 847-856
• 107 Sarwer D B, Durlak J A. A field trial of the effectiveness of behavioural treatment for sexual dysfunctions.  J Sex Marital Ther. 1997;  23 87-97
• 108 Schneidman B, McGuire L. Group therapy for nonorgasmic women: two age levels.  Arch Sex Behav. 1976;  5 239-247
• 109 Segraves K B, Segraves R T. Hypoactive sexual desire disorder: Prevalence and comorbidity in 906 subjects.  J Sex Marital Ther. 1991;  17 55-58
• 110 Sherwin B B, Gelfand M M, Brender W. Androgen enhances sexual motivation in females: a prospective, crossover study of sex steroid administration in the surgical menopause.  Psychosom Med. 1985;  47 339-351
• 111 Shifren J, Braunstein G, Simon J ,. et al . Transdermal testosterone treatment in women with impaired sexual function after oophorectomy.  New Eng J Med. 2000;  343 682-688
• 112 Sipski M L, Alexander C J, Rosen R. Sexual arousal and orgasm in women: effects of spinal cord injury.  Ann Neurol. 2001;  49 35-44
• 113 Sipski M L, Rosen R C, Alexander C J, Hamer R M. Sildenafil effects on sexual and cardiovascular responses in women with spinal cord injury.  Urology. 2000;  55 812-815
• 114 Snyder A, LoPiccolo L, LoPiccolo J. Secondary orgasmic dysfunction II: case study.  Arch Sex Behav. 1975;  4 277-283
• 115 Sotile W M, Kilmann P R, Follingstad D R. A sexual enhancement workshop: Beyond group systematic desensitisation for women's sexual anxiety.  J Sex Marital Ther. 1977;  3 249-255
• 116 Sotile W M, Kilmann P R. The effects of group systematic desensitisation of orgasmic dysfunction.  Arch Sex Behav. 1978;  7 477-491
• 117 Spector I P, Leiblum S R, Carey M P, Rosen R C. Diabetes and female sexual function: A critical review.  Ann Behav Med. 1993;  15 257-264
• 118 Teusch L, Scherbaum N, Bohme H, Bender S, Eschmann-Mehl G, Gastpar M. Different patterns of sexual dysfunctions associated with psychiatric disorders and psychopharmacological treatment. Results of an investigation by semistructured interview of schizophrenic and neurotic patients and methadone-substituted opiate addicts.  Pharmacopsychiatry. 1995;  28 84-92
• 119 Trigwell P. Sexual dysfunction in women with diabetes mellitus: Addressing impaired arousal.  Sexual & Marital Therapy. 1999;  14 385-397
• 120 Valleroy M L, Kraft G H. Sexual dysfunction in multiple sclerosis.  Arch Phys Med Rehabil. 1984;  65 125-128
• 121 Van der Velde J, Everaed W. Voluntary control over pelvic muscles in women with and without vaginistic reactions.  International Urogynaecology Journal & Pelvic Floor Dysfunction. 1999;  10 230-236
• 122 Wallace D H, Barbach L G. Preorgasmic group treatment.  J Sex Marital Ther. 1974;  1 146-154
• 123 Watson J P, Davies T. ABC of mental health: Psychosexual problems.  BMJ. 1997;  315 239-242
• 124 Wincze J P, Caird W K. The effects of systematic desensitisation in the treatment of essential sexual dysfunction in women.  Behav Therapy. 1976;  7 335-342
• 125 Zajecka J. Strategies for the treatment of antidepressant-related sexual dysfunction.  J Clin Psychiatry.. 2001;  62 (Supl 3) 35-43
• 126 Zimmer D. Does marital therapy enhance the effectiveness of treatment for sexual dysfunction?.  J Sex Marital Ther. 1987;  13 193-209